Ethical Framework Of Public Health Essay

While the moral backing for public health in its current state may be sound, what many researchers fail to understand is that the many moral failings of its predecessors that color the legacy of public health internationally and at home. As discussed in the chapter “Colonial Medicine and its Legacies” within the textbook Reimagining Global Health arranged by Paul Farmer, before the conception of global health there was international health which sought to distribute health as a good horizontally across international, political lines. Under the framework of international health, public health workers became agents of a cold war enmeshed in the fiscal, geopolitical, and territorial struggles between two hegemons rather than the holistic value of community health. While international health as a framework has largely been abandoned, much of its rhetoric can be found within our current framework of public health such as the enumeration of certain parts of the world as "1st world", "2nd world",

and "3rd world". It is in this similar manner that the most controversial iterations of public health find their way into the current framework, including Tropical Health and Colonial Health.

In fact, the very idea of treating a populace as a patient wasn’t conceived until slave masters needed a way to keep their slaves healthy at the most effective cost.
As Tropical Health and Colonial Health portray, Public Health originates from bourgeois needing to sustain and proliferate the many disadvantaged and enslaved subjects below them, and in doing so protecting their own health and sustaining extractive and capitalistic economies. I begin my case study into the limitations of the ethical framework of the Public health researcher with this historic background to qualify the cases I will be presenting, as it could be argued that the cases presented are not representative of public health because they do not fall into current paradigm of global health. However, I believe a temporal analysis is necessary to maintain context for these issues and to create a more accurate image of public health as it is today, through the analysis what values it left

behind and what values it retained. While the field of bioethics would hold that public health is completely transfigured from its origins, many cynics and realists would also hold that the parading of international health workers from the U.S. is no different from the missionaries of the colonial days who committed cultural rape on the disadvantaged they sought to help. Whether either stance is valid is irrelevant to the immutable fact that there is a disconnect between the ethical framework of public health, the reality of public health, and history, and I believe that this is the first limitation of the ethical framework set out by prevailing public health and bioethics discourse. One of the many limitations that will be found in our discussed cases, Tuskegee Syphilis Experiment, Kennedy Krieger Institute Review, and Flint, Michigan, which will describe how and why public health officials and researchers failed the public. I situate my examples in the U.S. not only for the challenge but for the nuance and relevance the U.S. based examples allow for, this is under the metaphoric framework of many areas of the U.S. being “third-world” entities (African-American poverty stricken neighborhoods and ghettos) and treated as such by the larger first world diaspora (white suburbia) in the context of legislation, structure, and public health measures.
The Tuskegee Syphilis Experiment

The Tuskegee Syphilis Experiment was started in 1932 by a team of doctors and nurses, Dr. Raymond A. Vonderlehr, Dr. Eugene Gribble, and Nurse Eunice Rivers from the United States Public Health Service and the Tuskegee Institute for social hygiene. The cause of the experiment was noble enough, the eradication of the Syphilis endemic in the black males of Macon County through education, mercury rubs, and the improvement of "social hygiene" or sexual etiquette. However when resources ran dry, this experiment gained an ulterior motive of creating racial equality through the countless deaths of black men. The experiment wished to liken itself to the Norwegian Syphilis experiment, The Oslo Study of Untreated Syphilis of 1928, which described the gruesome deaths of several caucasian males after experiencing the tertiary and final stage of Syphilis. Lead doctor, Dr. Vonderlehr, believed that they could use the opportunity created by a lack of resources to analyze the dead and dying black men and prove that the white man and the black man were biologically similar since current technology lacked the means to do so ethically.
Forty years after its conception the experiment was shut down by a whistleblower and a class action lawsuit was filed for the extensive biological damages incurred. The experiment was lauded as one of the most ethically infamous experiments in public health history. From this experiment, several ethical provisions were created including the concept of informed consent and beneficence as the study lacked both. Patients within the study were not told they were being denied medical treatment or even that they were sick with syphilis in the first place, it was advertised as a benefits programs where the black males received medical services, burial insurance, and financial stipends they would not have received otherwise. Also sometime in the middle of this study Penicillin was released and promoted as a successful cure for syphilis, at this point the concept of equipoise within this study would have yielded that the study be cancelled and the funds dedicated to fully curing the patients involved, as the biological costs would not validate the "success" of the study.
Beyond this, Dr. Vonderlehr as the primary investigator was directly attacked for his paternalistic racism that invalidated his patients the right to even choose another source of experimentation or treatment. Patients who attempted to leave the study were turned back to Dr. Vonderlehr program untreated. Despite being considered a "racial liberal" of his time, a man who truly wanted the equality of the races and believed that his method would be the best at attempt at doing so. He acted as if the black men of this study population were incapable of finding a road to equality without his study and incapable of finding that road without extreme sacrifice. This was representative of the prevailing Health paradigm of the time which was largely mired in the logic of "Social Hygiene" which also fought for public health as a means to protect white people from "black" plagues. This notion was surprisingly rampant and indicative of the views of the public at the time, the experiment for the longest time was viewed as necessary and just work. It is only in retrospect was it seen as atrocious which was why it was continuously condoned and funded throughout the decades. It’s because of this support I believe the many advising organizations in this study including the Tuskegee Institute of Tuskegee College, USPHS, and the CDC played integral roles in this case and must be differentiated from the primary investigator.
Kennedy Krieger Institute and the Lead Paint Hazard
The Kennedy Krieger Institute (KKI) is a children’s health facility affiliated with John Hopkins University in Baltimore, Maryland. Between the years of 1993 to 1995, it researched low-cost lead abatement procedures to counteract lead poisoning in public housing. The study found that 95% of low-income housing contained lead-based paint, that nearly 50% of the African-American children living in these neighborhoods had elevated blood lead levels, - deemed "moderate" by current CDC standards – and that all three of its abatement procedures proved successful in reducing blood lead levels from their original levels (David Buchanan et. al). Despite its honorable findings the Kennedy Krieger institute was taken to court in KKI v. Grimes.
The researchers of KKI were charged with failing to give informed consent, not giving special status to the disadvantaged subjects of their study, and failing to be impartial on their internal research review. The KKI study was likened to the Tuskegee Syphilis Experiment due to the idea that it exploited the disadvantaged black children and did not give them just and complete remediation from lead poisoning. While the case was largely thrown out and many of the claims invalidated, the need for an outside reviewing board did not go unnoticed and became a staple of biomedical research. Beyond the case’s ethical soundness, another interesting point about this case is the unjust outrage that surrounded it. The outrage proved that there was a significant lapse between what the public wanted out of public health and what they put in. In this case, highly structured and policed initiatives that resulted in incremental changes for afflicted populations was seen as insulting and derailing in light of the drastic social reforms the populace truly wanted. In this case, once again, the lack of boundless fiscal resources and social oversight was their undoing.
The Toxic Water Crisis in Flint, Michigan
In April 2014, the state government of Michigan and the city government of Flint both agreed to move from the city’s original water source, Egan, to the more obvious and unused water source that snaked through the city, the Flint River. The city believed that the water would be rendered usable after a simple phosphate treatment and that the change would yield $5 million in savings for the impoverished city. However, after living with this change for 21 months large swathes of the population were afflicted with lead poisoning and the loss of infrastructure and health had amounted to 1.5 billion dollars (Stephanie Athey et. al).
This crisis is relevant to this discussion because the water quality and management of hazardous waste falls under the surveillance arm of Public Health research. The public health specialists of Michigan, in combination with a state government that has lost its moral center, had ultimately failed the young, disproportionately black, children of Flint by failing to report the toxicity of their drinking water and failing to create measures to rectify it. Due to limited resources, most of Michigan’s local health departments failed to provide any services that could buffer the damages from the crisis including lead testing or proper investigation, 74% of public health officers stated that the lack of resources was the primary cause of the crisis (Brie D. Sherwin).
The pure lack of finances and resources is not prima facie, and interventions cannot be ethically evaluated if they were never initiated in the first place or were severely constrained and reimagined due to the lack of money. This is why the current ethical framework posed by prevailing bioethics theory regarding proper public health research is inadequate, it doesn’t leave any obvious measure for the evaluation of resource constraints on interventions, or any ethical framework for the ideal Public Health Researcher to follow when resources suddenly reduce. It leaves the researcher in a sort of moral gray area where the decisions of what to do with the remaining funds are left to their internal bias or sense of paternalism. Then, as we have seen in the previous examples, the public judges these researchers for their poor decision-making in these situations despite that the researchers are given no moral handbook in these particular situations and that the biases that these researchers display are inherent to public health since its conception. Is it a coincidence that the dilemmas found in Flint, Baltimore, and Tuskegee have been situated in the poverty of African Americans instead of the more affluent majority? Could we be seeing the results of the true goal of Public health; not community health for the sake of community health but rather community health for the sake of the affluent?